Causes of Infertility

Male Infertility & Investigations

Most people attending an infertility clinic will be familiar with the fact that one in six couples experience problems achieving a pregnancy. However, not so many are aware that of these, almost a third have some type of male factor infertility. Whilst infertility due to female problems is now often talked about in a fairly open way this is often not the case for men, perhaps because a lot of people still wrongly associate fertility with virility.

Bath Fertility has helped many men become fathers and can offer the latest advanced procedures including hormone profiles, chromosome and genetic testing, Sperm DNA fragmentation, fragility test and surgical retrieval of sperm. It is also quite often possible to improve your sperm count with some simple remedies which are listed further on.

Under the general heading ‘male factor’ there are several types of problem that can cause subfertility; many relate to sperm function although sexual problems (such as impotence or lack of ejaculation) can also affect male fertility. Male partners will attend the clinic for a semen analysis. There is a private room set aside at the Clinic for semen production. Just outside the room is a discreet hatch where samples are left with the appropriate form.

Our fertility specialists will cover male infertility as part of the initial consultation and if tests show that you have a fertility issue then you will be able to discuss your various options with the consultant.

Some men struggle to come to terms with their fertility issues and feel it makes them less of a man. We offer free counselling to both men and women, either individually or as a couple to help you cope better with the emotional journey infertility can take you on.

Types of Male infertility

There are several different types of male infertility, and our specialists use semen analysis techniques to identify these.

The most commonly seen suboptimal factors are:

Oligozoospermia: low sperm count (less than 15 million sperm per ml of semen) where there are not enough sperm in the ejaculate to reliably reach an egg for fertilisation. Although 15 million may sound plentiful, in terms of fertility values below this can be a significant issue. For men whose count is significantly low then IVF alone may not work and ICSI (intracytoplasmic sperm injection) where a single sperm is injected into each egg to ensure fertilisation may be indicated. For extremely low sperm counts with no obvious explanation, genetic tests may be offered: very low counts are occasionally associated with missing parts of the male Y chromosome or can be associated with the presence of a cystic fibrosis gene. which could be passed on to any resulting male children, along with the associated infertility.

Azoospermia: no sperm in the ejaculate.

Asthenozoospermia: low sperm motility where less than 32% of sperm are moving and/or their progression (how fast they swim) is too weak for them to reach an egg. ICSI is usually indicated in cases where motility is compromised to the extent that there are insufficient strongly-swimming sperm for IVF.

Teratozoospermia: high proportion of abnormally-shaped sperm. Most semen samples have more than 4% normal sperm, but in those with less than this then some structural problem with the sperm may be suspected which could reduce the chance of fertilisation, both in vivo (after intercourse) and in vitro (with IVF). ICSI is recommended for sperm with high abnormal shape (morphology).

Antisperm antibodies: occasionally found in semen and indicate an abnormal immune response to sperm. Antibodies are substances made by the body as a defence against foreign ‘invaders’ such as bacteria or viruses. Sometimes a man may produce antibodies against his own sperm, especially if there has been injury to or infection of the testicles or vasectomy reversal. Antisperm antibodies can cause infertility because they can make the sperm stick together (agglutinate) so that they are unable to swim. Even if antibodies do not cause sperm to agglutinate they may affect the way sperm swim or can stop sperm attaching to an egg. Where the majority of sperm are affected by antisperm antibodies ICSI provides the best option to maximise the chance of fertilisation.

Causes of Male infertility

It is not always possible to pinpoint the cause of a suboptimal semen analysis, but common causes include:

Previous infection may cause scarring or blockage of the sperm transport tubes

Surgery (e.g. to correct undescended testes or a hernia) can cause scarring or production of antisperm antibodies. Vasectomy reversal, while often successful, sometimes results in poorer quality sperm than before

Injury can damage the testis and affect semen quality

Hormonal disorders diagnosed by blood tests

Chromosome disorders: see Y chromosome in Glossary

Genetic disorders e.g cystic fibrosis gene

Radiotherapy/chemotherapy for treatment of cancer can affect sperm production; in about half of cases this can return to normal within 1-5 years

Retrograde ejaculation where sperm is produced but is ejaculated backwards into the bladder

Cigarette smoking, cannabis use and excessive alcohol intake can all reduce sperm quality

Heat stress to the testes e.g. from very hot baths, working for prolonged periods in hot conditions which overheat the testes, wearing very tight underwear and/or clothing. Using a laptop computer on your lap rather than a desk has also recently been suggested to affect sperm production!

Improving your sperm count

One piece of advice that is often given to subfertile men is to avoid wearing tight underclothing and avoid hot baths. This is so that the testicles can remain at the temperature nature intended, which is about 4 degrees cooler than normal body temperature. Higher temperatures can result in higher proportions of abnormal looking sperm. Bathing the testicles in cold water is no longer recommended as it is not beneficial – a source of relief to many!

It is a good idea to maintain a healthy lifestyle, including normal body weight, healthy diet and moderate exercise. There is some evidence to suggest that taking vitamin and mineral supplements (especially vitamins C and E, Selenium and zinc) can improve sperm quality for some men. This will not help for all men but if taken in accordance with the instructions on the bottle will not do any harm.

Excessive alcohol consumption or smoking can be detrimental, as can the use of recreational drugs, so these should be eliminated or cut down as much as possible. We probably all know of men who smoke a lot, drink heavily and have a poor diet yet have managed to father children with no trouble. The cruel fact is that for men with a high concentration of sperm these factors will have less impact, because even if their sperm count is reduced there are still plenty of sperm there.

Some of the chemicals used in industrial processes and agriculture are believed to have an adverse effect on male fertility. In the same way some drugs used for treating medical conditions can affect sperm counts. It is important therefore that you tell the doctor if you are undergoing any other medical treatment.

Female Infertility & Investigations

Around one third of infertility cases are due to known female causes, including tubal disease, endometriosis, ovulatory disorders, age-related factors and mucus hostile to sperm.

Unexplained infertility, where the cause is not known, accounts for another third of cases, while male factor infertility makes up the remainder.

Before embarking on your IVF journey, it is important you to have the necessary investigations and assessments.

Ask your GP whether you meet the criteria to be referred through the NHS to reproductive medicine. The RUH Reproductive Medicine clinic is hosted at Bath Fertility.

Tubal Disease

Diseased or damaged fallopian tubes (‘blocked’ tubes) account for about 20% of all cases of infertility in the UK.

This may be caused by pelvic infections such as chlamydia or pelvic inflammatory disease, or damage due to ectopic pregnancy and scar tissue formation following other pelvic surgery. If one or both tubes are blocked, eggs and sperm cannot meet for fertilisation and so conception does not happen.

Despite the improvements in the surgery techniques used to repair blocked or damaged tubes, conception rates remain disappointingly low. In such cases IVF is the treatment of choice as it bypasses the blocked tubes to collect oocytes (eggs), fertilising them in the laboratory and then replacing the embryos directly into the uterus (womb).

Endometriosis

Endometriosis is a condition where the presence of functioning endometrium is found outside its normal environment, for example on the ovaries or tubes.

Its presence here may lead to adhesions or scar tissue, and it can cause painful periods or pain during intercourse.

The damage caused by endometriosis to the fallopian tubes or ovaries is diagnosed by a laparoscopy. IVF is the preferred treatment for infertility caused by endometriosis where other methods have not helped.

Polycystic Ovaries and Polycystic Ovarian Syndrome (PCOS)

Polycystic ovaries are quite common affecting as many as one in five women, many of whom may be completely symptom-free.

Polycystic ovaries contain multiple small cysts or follicles in which the developing eggs may not fully ripen prior to release (ovulation) due to hormone imbalances and accumulate in the ovaries.

Some women with polycystic ovaries have PCOS. They may have a few or several symptoms including irregular, infrequent or no periods, complexion problems and excess weight.

PCOS may be treated in several ways, including taking oral contraceptives (‘the Pill’) to try to temporarily regulate the cycle. Surgery may be used to ‘kick-start’ the ovaries, or special diets and exercise may help some to re-balance their hormones and re-establish ovulation.

For those with weight problems, weight loss is a key factor for a successful outcome.

The drug Clomiphene may be used to induce ovulation. Tamoxifen can be used in a similar fashion. For those who are therapy resistant laporoscopic ovarian spot diathermy can be effective.

If these treatments are unsuccessful then IVF may be recommended. Polycystic ovaries are sometimes unpredictable in their response to drugs used to stimulate the ovaries to produce eggs, either not responding at all or over-responding and producing too many follicles which may contain eggs of sub-optimal quality. Most women can be treated with careful monitoring of their cycle to prevent or manage ovarian hyper stimulation syndrome (OHSS).

Age and infertility

Fertility drops dramatically with age. At the age of 35 the chance of pregnancy is half that of age 25. At 40 years of age the chance is much smaller again. Beyond the age of 43 the chances are further reduced.

This is due to a combination of factors including a decreased supply of eggs in the ageing ovaries, an increased rate of chromosomal abnormalities in older eggs, and a higher risk of miscarriage for those who do become pregnant.

Older women (those 38 and over) may be treated with IVF providing their ovaries respond adequately to the drugs used to produce eggs.

The likelihood of this can be estimated by blood tests to establish hormone profiles and ultrasound scans.

Pregnancy rates for older women having assisted conception treatment are generally lower than those for women under 38, and these couples may need to consider using donated eggs or embryos.

At Bath Fertility we offer all treatments to women up to the age of 44. Hormone assessments will help us to provide you with a realistic idea of a positive outcome.

Unexplained infertility

Unexplained infertility, where no obvious cause can be found, affects about one-third of couples who have difficulty conceiving.

Female Investigations

Tubal Patency

Tubal disease may be diagnosed with a combination of blood tests such as chlamydia and examinations.

A hysterosalpingogram (HSG) may be performed. This is a type of X-ray examination that shows inside the uterus and fallopian tubes and indicates whether they are open.

Recently we have introduced the Hycosy ultrasound test which is tending to replace the HSG and avoids x-rays.

If there is a reason to suspect tubal damage or endometriosis we will offer a laparoscopy for a complete assessment.

Laparoscopy

Laparoscopy is a minor operation where a small telescope (laparoscope) is passed through a tiny cut in the belly button and a view of the pelvic organs is obtained before flushing coloured dye through the cervix into the uterus and tubes to check whether they are open (patent) or blocked.

Endometriosis, adhesions and polycystic ovaries may also be seen and diagnosed this way.

Hormone profiles

Blood samples may be taken to obtain hormone profiles. Those usually measured include FSH (follicle stimulating hormone), progesterone, LH (luteinising hormone) and very occasionally oestradiol may be monitored during treatment.

FSH is measured to help discover any signs of decreasing follicle supply in the ovaries (diminishing ovarian reserve) that occur with ageing, as well as to establish what dose of follicle-stimulating drugs is most suitable for IVF treatment.

LH and progesterone levels may be checked to detect when and if ovulation is occurring, and may be used to determine treatment day for patients having frozen embryo transfers or IUI.

Polycystic Ovarian Syndrome (PCOS) is diagnosed by a combination of ultrasound scan to look at the ovaries, along with blood tests to check for hormone imbalances of FSH and LH.

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